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Drexel University College of Medicine Common Symptoms DREXEL UNIVERSITY COLLEGE OF MEDICINE COMMON SYMPTOMS: A GRID OF DIFFERENTIAL DIAGNOSIS FOR REVIEW Rev. December 2018 Generally, for each diagnosis there appear first attributes of the symptom, then associated symptoms, then risk factors, then physical findings (in italics). This is a work-in-progress: more symptoms will be added in due course. The order of listing is Cardio-Pulmonary, GI, HEENT, Musculo-skeletal, general. BEWARE: This table represents obvious simplification and selection. Of course, few patients will show all the findings for a given diagnosis, and in turn few findings are entirely specific to one diagnosis! Particularly common causes are in blue. Wherever possible, the listed attributes are supported by evidence obtained by publications since 1990. An asterisk (*) indicates that such literature is available for the complaint or at least some disorders causing the complaint. Otherwise, the listings reflect consensus or traditional teachings. The most indicative findings are in bold. Prepared by Steven J. Peitzman, MD, FACP symptom-table-rev-12-2018 December, 2018 SYMPTOM DIAG. 1 DIAG 2 DIAG 3 DIAG4 OTHER DXs CHEST PAIN Ischemic Heart Ischemic Heart NON-Ischemic Pericarditis Dissecting Aortic Disease:Angina* *Disease:Acute MI Causes [see also to Aneurysm Exertional Central in chest the right]* Pleuritic Felt as pressure, Radiation to arm(s), Not exertional Central in Acute Onset weight, discomfort jaw Described as sharp chest Severe Relieved by rest <6 Duration>30 or stabbing Radiates to arms, “tearing” quality minutes minutes Related to position jaw Pulse deficits Central in chest Assoc: sweating, Age < 40 Fever Focal neuro finding Radiation to nausea Assoc. with Rub arm(s), jaw Same risk factors as dizziness, flushing (Most are Male, D.M, smoker, angina (Note: includes idiopathic/viral, but high lipids Physical findings of anxiety-induced can be assoc. with Corneal Arcus CHF (minority) chest pain, common cancer, autoimmune Ear-lobe crease and sometimes disease) Carotid bruit assoc. with hyperventilation) Chest Pain Other (Con’t) esophageal-based (GERD, spasm) Chest wall Inflammation Palpitations/ ANXIETY Hyperthyroidism* Panic Attack Dysrhythmia *(esp Other Causes: PACs or PVCs, Racing Heart Triggers (situations) Sweats Discreet episodes episodic A. Fib., Anemia Other somatic Heat intolerance Sweats Parox. Adrenergic drugs complaints Nervousness Shortness of Supraventricular Tachycardia) Otherwise normal Enlarged thyroid breath/choked exam Tremor of hands feeling Sudden Other indicators of Hyperactive DTRs Shakiness onset/cessation stress or anxiety (note: fewer signs (these are DSM Sense of “flip-flop” and symptoms in criteria) or irregularity older age) Awareness in bed Heart rate >90 Syncope or near- bpm except in >60- syncope y-o Sense of pounding in neck (for PST) HR > 150 (ie, more than most sinus tach) A waves in neck veins COUGH, Post-URI Airway Asthma POST-NASAL GERD COPD*: smoking PERSISTENT Hyper-reactivity DRIP history; dyspnea on (> 3 WEEKS), Shortness of breath (also called Upper Heartburn, acid exertion; wheezing; History of acute Chest “tightness” Airway Associated taste in mouth diffusely decreased in otherwise URI [But other sx may Cough) [BUT, many or breath sound well-seeming be absent in cough- most patients lack intensity; early adult (note: May go on for >4 variant asthma] Patient aware of GI symptoms.] inspiratory crackles weeks! FH of asthma, post-nasal drip Response to anti- mutifactorial allergy, or eczema Chronic rhinitis GERD Rx Also: causation is Sometimes Wheezing Response to nasal ? Hoarseness in common) wheezing steroid some Eosinophilic bronchitis ACE inhibitor Sarcoidosis Lung Cancer Tb Bronchiectasis SHORTNESS Asthma COPD CHF Anemia Pneumothorax Pneumonia OF BREATH Episodic Exertional Exertional Bleeding often GI Pericardial disease Coughing Coughing Positional(orthopnea) Headache Angina “Tight” feeling Cigarets Past MI Fatigue Anxiety Allergy, eczema Wheezing Hypertension Pallor (conjunctival Pleural fluid Wheezes Quiet breath Edema rim, nails) Pulm. Embolus sounds Crackles Early insp. crackles NVD S3 ABDOMINAL Appendicitis* Cholecystitis* Pancreatitis Diverticulitis Ruptured Ectopic PAIN, ACUTE RLQ RUQ or epigastric Epigastric LLQ Lower quadrant Migration of pain location Felt in back Fever Tenderness and Pain before Vomiting Fever History of rebound vomiting Pain radiation to Vomiting constipation Collapse Local tenderness shoulder Alcohol Local tenderness & Vaginal bleeding Guarding, rebound RUQ tenderness Abdominal rebound Missed period Fever Murphy Sign tenderness and Rebound ABDOMINAL (5) (6) PID (7) Perforated (8)Kidney Stone PAIN, ACUTE OBSTRUCTION* Stomach/Intestine (con’t) Lower quadrant Typically begins in Crampy pain pain Generalized pain flank Vomiting Discharge Shocky Patient wants to Absence of b.m. Unprotected sex Hx of ulcer, move around Past surgery Local peritoneal NSAIDs, Radiation to Hyperactive, high- signs Guarding, Rebound genitals pitched bowel Tender Cervix Urgency/frequency sounds early, ileus Hematuria later Sometimes vomiting Distention Lack of local Hyper-resonance findings on abdo exam; sometimes CVA tednerness ABDOMINAL Irritable bowel Gall Bladder GERD ULCER “Non-specific” PAIN, syndrome* Disease* Pancreatitis RECURRENT “heartburn” Epigastric Recurrent “Crampy” pain RUQ or epigastric Worse supine Periods of pain obstruction Relieved by bowel location Worse with separated by movement Vomiting caffeine, “acid” months Diarrhea and/or Pain radiation to foods, chocolate Melena constipation shoulder Relieved by Alcohol Sense of being RUQ tenderness antacid Smoking “bloated” PE usually egative VOMITING, Gastroenteritis Bowel Obstruction Diseases of Major Drugs (selected) Labyrinthitis/ ACUTE and especially Abdominal Organs Meniere’s (almost always ingestion of pre- Pain, not highly Anti-neoplastic associated with formed toxin (see localized Pancreatitis Many antibiotics Vertigo “diarrhea”) History past surgery Hepatitis Digoxin Nystagmus nausea) Abdo. Distention Cholecystitis Colchicine and tympani (usually associated Opiates High-pitched bowel with pain) NSAIDs (not sounds then ileus common) VOMITING, Gastroenteritis Hepatitis esp A Early Pregnancy Medications (see Other Causes above) (selected) REPEATED Associated with Contaminated food Opportunity without Pain as diarrhea eg shellfish Missed menses and Self-induced Major Pre-formed toxin as Jaundice but may be Other signs of Binge drinking Symptom (ie with staph shows absent esp. early pregnancy Drug withdrawal not vomiting>diarrhea Tender liver (RUQ) Motion sickness Sometimes fever Dark urine Uremia pancreatitis, (viral or bacterial) Gastric outlet or acute bowel Foods to ask about: emptying defect (eg obstruction) eggs, pastry. diabetic gastroparesis) HEADACHE Migraine* Tension Meningitis* Brain Tumor Head Injury Intrancranial bleed Unilateral Generalized Fever Progressive (if chronic: Pulsating Absence of other Mental status Worse bending over subdural) Nausea findings change (esp. if + Neuro findings Cluster Headache Sens. to light or bacterial) Severe HBP noise Blunted mental Caffeine overuse or 4-72 hrs status withdrawl + Family Hx Resistance to Medication overuse flexion of neck headache (bacterial) DIZZINESS Benign Positional Labyrinthitis Hypovolemia and Stroke/TIA (rare Other Causes (Note: many (or “Positioning”) Postural as cause of Vertigo* Hypotension* dizziness alone) Meniere’s cases are multi- A single, extended Syndrome (triad of causal especially Fleeting vertigo and period, days to Feeling of Sudden onset episodic vertigo, in elderly sometimes nausea weeks faintness esp. on Other neuro tinnitus, hearing persons) with head Sometimes there standing symptoms loss) movements has been a Diarrhea, vomiting, Older age, risk Esp. turning over preceding viral blood loss factors for Psychosomatic/ in bed syndrome Increase in heart vasc.disease psychiatric nystagmus, nystagmus rate on Nystagmus of any provoked falls toward side of standing>30 bpm type Migraine presenting nystagmus (Dix- inner-ear lesion Drop in syst P >20 Other neuro signs: as vertigo Hallpike when walking mmHg eg, diplopia, speech maneuver) disorder, focal weakness SORE Viral Streptococcal* Mononucleosis Gonococcal Peritonsillar abscess THROAT URI symptoms Fever Persistence Diphtheria NO cough Young adults Nodes Fatigue Exudate Rash Splenomegaly KNEE PAIN, Septic Joint Gout Rheumatoid Pseudogout Arthrits (is usually Hemarthrosis in acute with Fever Extreme pain bilateral) patient on Swelling (non- IV drug use Past symptoms in Coumadin traumatic) Gonorrheal toe Morning stiffness Bursitis esp. pre- symptoms Metabolic Joint involvement patellar Fever, chills syndrome elsewhere, esp. Warm, red, swollen, On thiazide hands in PIP and tender Exquisite MPs: swelling, tenderness even to tenderness light touch (if classic) Warm, swollen Surrounding soft tissue swelling KNEE PAIN, Osteoarthritis Patello-Femoral Bursitis Rheumatoid Pain referred from Syndrome arthritis (see hip-joint disease subacute or Older age (“chondromalacia”) Pre-patellar: above) (clue: no findings at chronic Morning stiffness Repeated pressure all in knee) but < 30 minutes Age < 35 with on knee Pain felt medially exceptions (“washerwoman”); in knee Pain especially on redness & Past injury to knee going up or down tenderness over or leg (not needed) stairs lower patella. Non-warm Pain, crepitus, or Anserine: pain, Bony enlargement ‘grittiness’ with tenderness medially Crepitus with ROM pressure on patella 5-6 cm below joint Tenderness at against femur
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